Does an unborn child or child under the age of 6 live at this address? Yes No Unknown

If a child under the age of 6 lives at this address, what is the child's date of birth/age:

Does a child under the age of 6 visit this address at least 2 different days within the same week, at least 3 hours per visit totaling 6 hours per week, and combined annual visits of 60 hours per year? Yes No Unknown

If a child under the age of 6 visits this address, what is the child's date of birth/age:

NOTE: Child visitation requirements are for owner occupied participants only. Child visitation requirements (the above two questions) are NOT needed for rental properties.

* IF YOU RENT

* If you Rent, provide Landlord's Name:

* If you Rent, provide Address:

* If you Rent, provide Phone Number:

If lead is found during the assessment free lead based paint remediation may be available.

Your online form submission will be sent to CAC Housing & Energy Services.

We also provide a PDF of the form that you can download, fill out, print and then mail to CAC Housing & Energy Services, P.O. Box 1650, Knoxville, TN 37950-1650. Or you can take the printed PDF form to your nearest CAC neighborhood center. Please call 865-244-3080 with any questions.